Early Intervention Colorado  Autism Guidelines for   Infants and Toddlers    These guidelines and other materials are avai...
Colorado Department of Human Services                       Division for Developmental Disabilities                       ...
Table of ContentsPreface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...
PrefaceIn July 2009, the Colorado Department of Human           mandates that appropriate services be based onServices, Di...
IntroductionThe arrival of a new baby brings joy and happiness to      A diverse collection of behavioral patterns arefami...
Guiding PrinciplesThe crafting of this set of guidelines has been            are done with the family. Families have a dec...
Autism Center’s National Standards Project report■ Principle 3:                                               (2009) and t...
about fidelity. Capacity plays a particularly importantrole in decision-making when:                             ■ Princip...
8. Data is taken and analyzed on a routine basis; and        and their behavior. The principles are grounded in the9. Adju...
Whether a child is using an alternative■ Principle 9:                                             communication system or ...
Regretfully, this simple and seductive formula is             can assume that skill acquisition is occurring. Insteadhighl...
approach to IFSP design that addresses all relevant          starting something new and different. During thedomains of pe...
Detailed Guidance for KeyPractice IssuesThe following sections offer a wide variety of both             moving the service...
to support the delivery of services that are              Question 5.individualized, evidence-based and                   ...
c) Adaptive—Skills such as dressing, hand washing             process and helps determine what skills or behaviors   and t...
affected by ASD or challenging behaviors. The              intensive and costly than Level 3 strategies. Still, forstrateg...
LEVEL 3:                                                  Individualized                                             Inten...
and then interrupted by the caregiver with the               that the child communicate or socially interact can beexpecta...
deliberately and, always, with awareness of what the          peers. They illustrate such environments withinstruction doe...
Morrier, 1999), modeling, various antecedent             Implications for Implementationprompting tactics, and peer-mediat...
EI Colorado Autism Guidelines
EI Colorado Autism Guidelines
EI Colorado Autism Guidelines
EI Colorado Autism Guidelines
EI Colorado Autism Guidelines
EI Colorado Autism Guidelines
EI Colorado Autism Guidelines
EI Colorado Autism Guidelines
EI Colorado Autism Guidelines
EI Colorado Autism Guidelines
EI Colorado Autism Guidelines
EI Colorado Autism Guidelines
EI Colorado Autism Guidelines
EI Colorado Autism Guidelines
EI Colorado Autism Guidelines
EI Colorado Autism Guidelines
EI Colorado Autism Guidelines
EI Colorado Autism Guidelines
EI Colorado Autism Guidelines
EI Colorado Autism Guidelines
EI Colorado Autism Guidelines
EI Colorado Autism Guidelines
EI Colorado Autism Guidelines
EI Colorado Autism Guidelines
EI Colorado Autism Guidelines
EI Colorado Autism Guidelines
EI Colorado Autism Guidelines
EI Colorado Autism Guidelines
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EI Colorado Autism Guidelines

  1. 1. Early Intervention Colorado Autism Guidelines for Infants and Toddlers These guidelines and other materials are available at www.eicolorado.org
  2. 2. Colorado Department of Human Services Division for Developmental Disabilities In Collaboration with The University of Colorado Denver School of Education and Human Development Phillip Strain, Ph.D., Principal Investigator Acknowledgements The Colorado Department of Human Services, Division for Developmental Disabilities would like to thank the families, early intervention staff and advocates who provided input on the Early Intervention Colorado Autism Guidelines for Infants and Toddlers. Suggested citation:Early Intervention Colorado Autism Guidelines for Infants and Toddlers (2010). Developed by the University of Colorado Denver, PELE Center, under contract with the Colorado Department of Human Services, Division for Developmental Disabilities (H393A090097). Permission to copy not required—distribution encouraged. Electronic version posted at www.eicolorado.org. Funded by the American Recovery and Reinvestment Act of 2009.
  3. 3. Table of ContentsPreface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iiIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Guiding Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Detailed Guidance for Key Practice Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Strategies for Designing Individualized Family Service Plans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 A Tiered Model for Thinking About Specific Needed Early Intervention Services . . . . . . . . . . . . . . . . . . 11 Implications for Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Evidence-Based Interventions and Measuring Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Established Interventions in the National Standards Project . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Case Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Monitoring Progress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Making Smart Decisions about Data Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Appendix A—Questions to Guide the Individualized Family Service Plan Planning Process for Children with Autism Spectrum Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Appendix B—About Our Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Early Intervention Colorado Autism Guidelines for Infants and Toddlers i
  4. 4. PrefaceIn July 2009, the Colorado Department of Human mandates that appropriate services be based onServices, Division for Developmental Disabilities, scientifically based research, are available statewidewith funding from the American Recovery and to all infants and toddlers, and meet theReinvestment Act of 2009, began collaborating with individualized needs of the eligible child and family.the University of Colorado, School of Education and The Guidelines are organized in different sections toHuman Development to develop the Early address the various target audiences of thisIntervention Colorado Autism Guidelines for Infants document. While anyone who has an interest in theand Toddlers. The purpose of these Guidelines is to provision of or receipt of early intervention servicesensure that infants and toddlers, birth through two for infants and toddlers with ASD will benefit fromyears of age,who have a diagnosis of, or reading the entire document, the “Guiding Principles”characteristics of Autism Spectrum Disorders (ASD) section is essential reading for all—administrators,receive early intervention services based on their policy makers, providers, families, and advocates.individualized identified need, and not on a Other sections of the Guidelines may be of more orprescriptive curriculum or treatment model. less utility to various readers. For example, all earlyThe Guidelines document is also intended to assist intervention providers working with infants andlocal early intervention programs to provide early toddlers with ASD and their families should beintervention services that are derived from evidence- familiar with and directly incorporate into theirbased practices, published research and early practice the strategies suggested in the “Designingchildhood clinical judgment that will increase the Individualized Family Service Plans (IFSP)” section.awareness and knowledge of families, providers, and Similarly, teams of providers and programearly intervention administrators. administrators may find the “Tiered Model for Thinking About Specific Needed Services” section toThe content of the Guidelines is compiled from a be useful in the overall design of systems and thereview of research-based programs and models, as allocation of resources. Families and providers arewell as state-of-the-art information from experts in always keenly concerned about the use of specificthe field of Autism Spectrum Disorders, and work practices with the best chance of producing desiredwith family members who have infants and toddlers outcomes. These readers may well find particularlywith ASD. The Guidelines approach early intervention valuable information in the “Evidence-Basedservice decisions consistent with the Individuals with Practices and Measuring Outcomes” section.Disabilities Education Act of 2004 (IDEA) thatii Early Intervention Colorado
  5. 5. IntroductionThe arrival of a new baby brings joy and happiness to A diverse collection of behavioral patterns arefamilies. This new beginning is met with anticipation exhibited by children with ASD. These behavioraland the desire to love and nurture the new family patterns are observed across multiple developmentalmember. Most parents follow their child’s areas and are highly distinctive (Volkmar, 1999). Thisdevelopmental milestones very closely. They watch diversity in the expression of ASD is what presentsand observe, compare achievements to that of others the greatest challenge for professionals and parentsthe same age, read informational books, search the looking for the most appropriate early interventioninternet, and ask questions of their primary care approaches. Each child requires an individuallyphysician, friends, childcare providers, or anyone tailored program of services in which the mostwho may offer some reassurance and insight on their appropriate collection of services is not always clear.child’s development. The child’s lack of specific social communication skills often hinders the child in expressing wants andDespite extensive information available to parents needs, regulating the actions of others, and engagingabout early childhood development, there are times in reciprocal social interactions. These deficits ina family is faced with puzzling questions about their particular result in the need for careful teachingchild’s development. They may wonder why their strategies to facilitate learning in young children withchild is not babbling by 12 months of age, or why he ASD. Early intervention services are very importantor she does not seem to relate to other children for enhancing the development of infants andduring story time at the library. What about those toddlers with disabilities, and they are especiallyscreaming episodes every time mom tries to crucial in determining the future language, social andcomfort? When a parent or referral source expresses behavioral outcomes of very young children withconcerns about a child’s language and ASD (National Research Council, 2001).communication, social, and behavioral development,it merits deeper questioning to analyze the root of The Early Intervention Colorado Autism Guidelinesthese issues and explore supports and services that for Infants and Toddlers offer a general orientationcan address these concerns. to the design and delivery of high quality services to infants and toddlers with ASD who are receivingAutism Spectrum Disorders (ASD) are neurological, early intervention services in Colorado. Thepervasive developmental disorders characterized by document is divided into three major sections. First,patterns of delay and difference in the development the reader will find a set of twelve Guidingof communication, social, and behavioral skills Principles that outline Colorado’s general guidance(Volkmar, 1999). The onset of these conditions around the development, implementation andgenerally takes place in the first years of life, and monitoring of early intervention services for infantsthese conditions may manifest in varying degrees and toddlers with ASD. The next major sectionboth across and within individuals. ASD affects provides more detailed information and guidanceindividuals of all socioeconomic levels and different around key practice issues for all providers andcultures (Autism Society of America, 1990; Scott, recipients of early intervention services including:Clark, & Brady, 2000). In the 1990s, it was believedthat ASD affected one out of every 250 individuals • Strategies For Designing Individualized Family(Brison, Clark, & Smith, 1988; Ehlers & Gillberg, Service Plans (IFSPs)1993; Sugiyama & Partington, 1998). More recent • A Tiered Model For Thinking About Specificfindings reflect an increase in prevalence and it is Needed Early Intervention Servicesnow believed that one out of every 150 individuals • Implications for Implementationcould be diagnosed within the autism spectrum(National Autism Center’s National Standards Project The final section provides detailed information on theReport, 2009). Established Interventions for individuals with ASD, case studies, strategies for monitoring progress and information about using data. Early Intervention Colorado Autism Guidelines for Infants and Toddlers 1
  6. 6. Guiding PrinciplesThe crafting of this set of guidelines has been are done with the family. Families have a decision-influenced deeply by a set of principles that reflect making role as members of the IFSP team. The teamboth the science of early intervention as well as a determines who will be involved in the program, whencore group of values. These principles are: services will take place and what will be the focus of the services. Families determine how they will be1. Services must be individualized for each child involved in implementing their child’s IFSP. Even and family. though the intervention may follow a specific2. Family involvement and participation is critical. curriculum, the infusion of intervention into daily3. Early delivery of intervention must be encouraged. activities and routines must be customized for each family. Therefore, it is essential that the IFSP be4. Families have a right to evidence-based practices. sensitive to and respectful of the enormous diversity in5. Intervention is based on an individualized family life circumstances that impact family member’s developmental curriculum designed to address participation in intervention. The life circumstances the specialized needs of the infant or toddler with include, but are not limited to: family structure, income Autism Spectrum Disorders. stability, informal supports, coordination with other6. Intervention is planned and systematic. relevant services, etc.7. Infants and toddlers with Autism Spectrum Disorders should have regular and deliberate ■ Principle 2: exposure to typically developing peers. Family involvement and participation8. Challenging behaviors are addressed using is critical. positive behavioral interventions and supports. A goal of early intervention services is to help families9. Intervention should focus on developing meet the developmental needs of their infants and communication skills. toddlers. Families are the first and most important10.The development of social relationships is integral teachers for their children. They are the constant in to successful outcomes. their children’s lives. Infants and toddlers learn as they11.Getting to quality outcomes is not just about experience life with their families. Service systems and hours of direct services. personnel change over time, but families maintain the continuity from day-to-day and year-to-year. Families12.The transition from the early intervention program become lifelong advocates for their children. to preschool special education and related services should be well planned. Families need to be actively involved in their children’s program, at a minimum, in the following ways:Each principle is described in detail below. 1. Planning and helping to decide what services their children will receive;■ Principle 1:Services must be individualized for 2. Instructing and assisting with activities of daily living and developing strategies for addressingeach child and family. the needs of their children, and“Individualization” means that each child’s and family’s 3. Evaluating the progress of their children.services are based on that child’s needs, strengths and Relationships between families and professionalsinterests and the family’s concerns, priorities and should reflect a respectful reciprocity where bothresources. This is different for each child and family parties learn from each other. Family members arebecause each child and family is unique and has not expected to be primarily responsible fordifferent needs and values. The development of the delivering the specialized services on the IFSP,intervention plan, known as the Individualized Family however, they are absolutely necessary partners inService Plan (IFSP), and ongoing changes in the plan intervention.2 Early Intervention Colorado
  7. 7. Autism Center’s National Standards Project report■ Principle 3: (2009) and the National Professional DevelopmentEarly delivery of intervention must Center on Autism Spectrum Disorders definition ofbe encouraged. evidence-based practices for children with ASD (2009). Moreover, families should have a right toEmpirical data support the value of early intervention services that address all the core deficits of ASD.(Fenske, Zalenski, Krantz & McClannahan, 1985;Harris & Handleman, 2000; Lovaas, 1987; Strain & Intervention selection is complicated and should beBovey, 2008). This makes a compelling case for made by a team of individuals who consider thepractices to expedite the delivery of services under unique needs and history of the infant or toddler withPart C of the federal Individuals with Disabilities ASD along with the environments in which he or sheEducation Act (IDEA). Therefore, parents and lives. However, in all cases, IFSP teams must selectproviders who suspect an infant or toddler of having established evidence-based practice (see “Evidence-ASD should insist on early screening. Based Interventions” section, pp. 17–27) for service delivery to any infant or toddler with ASD.To address this need for early screening, the M- Established Interventions have sufficient evidence ofCHAT™ (Modified Checklist for Autism in Toddlers) effectiveness. The IFSP team must give seriouswas developed for very young children older than 12 consideration to these interventions because a) thesemonths who show signs of ASD. It is designed to methods have produced beneficial effects for childrenscreen for social development, such as joint attention involved in the research studies published in theand pretend play, in comparison to typical infant and scientific literature and, b) access to methods thattoddler milestones. The M-CHAT™ can be useful in work can be expected to produce more positive long-narrowing down behaviors that may lead ultimately term outcomes. However, it should not be assumedto an ASD diagnosis for infants and toddlers and can that these methods will universally produce favorablehelp highlight the red flags associated with ASD so outcomes for all children with ASD.that early intervention can begin as soon as the childis found eligible for services. In addition to relying on Established Interventions first, the judgment of professionals with expertise inFamilies and children should not have to wait for working with the individual child with ASD must beearly intervention services while waiting for a medical taken into consideration (see “Strategies for Designingdiagnostic evaluation. The American Academy of IFSPs” section, pp. 9–11). Once methods are selected,Pediatrics recommends referring simultaneously for these professionals should collect data to determine ifa diagnostic medical evaluation and also to an early a method is effective. Professional judgment plays aintervention program as soon as an ASD diagnosis is particularly important role in decision-making when:suspected. Even without a formal diagnosis of ASD,children may qualify for and benefit from early 1. A method has been correctly implemented in the pastintervention services. and was not effective or had harmful side effects. 2. The method is contraindicated based on other■ Principle 4: information (e.g., the use of prompts for a childFamilies have a right to evidence- with a prompt dependency history).based practices. Moreover, the values and preference of the parents or other primary caregivers play an important role inPart C of the IDEA mandates that states have in effect a decision-making.policy that “ensures that appropriate early interventionservices based on scientifically based research, to the Finally, early intervention providers should be wellextent practicable, are available to all infants and positioned to correctly implement the selectedtoddlers with disabilities and their families…” (20 intervention. Developing capacity and sustainabilityU.S.C.1435(a)(2)). Families should expect that all of an established method may take a great deal ofservices delivered as part of the IFSP are based upon a time and effort, but all people involved in interventioncontemporary understanding of efficacious to infants and toddlers with ASD should have properintervention practices as articulated by the National training, adequate resources, and ongoing feedback Early Intervention Colorado Autism Guidelines for Infants and Toddlers 3
  8. 8. about fidelity. Capacity plays a particularly importantrole in decision-making when: ■ Principle 6: Intervention is Planned and Systematic1. A service system has never implemented the intervention. Many evidence-based methods are Intervention is carefully planned, concentrated, and very complex and require precise use of systematic. It involves assessing, planning, teaching techniques that can only be developed over time. and consistent measuring of progress with each2. A professional is considered the “local expert” for intervention step. Each step is coordinated toward a a given method but he or she actually has limited meaningful set of outcomes or goals. The only formal training in the technique. reliable way to determine if the intervention is effective is to be systematic and to measure progress3. A service delivery system has implemented a on a regular basis. It is important to note that many system for years without a process in place to indicators that are easiest to measure, such as ensure the intervention is being implemented vocabulary, intelligibility of words, or duration of correctly (with fidelity). engagement may not be as meaningful or important to the family as the sense of the child and family’s■ Principle 5: quality of life, such as reduced frequency ofIntervention is based on a developmental tantrums, ease of transition between home and othercurriculum designed to address settings, or the ability of family members to spendthe specialized needs of the infant or quality time together.toddler with Autism Spectrum Disorders. Systematic instruction relies on interventionIFSPs for infants and toddlers with ASD should be decisions that are driven by the results of databased on widely accepted principles of child collection. Data is used to measure the change in adevelopment. The instructional program builds on behavior or skill over time. For example, data may bethese principles and the child’s individual strengths taken on the frequency (how often) a behavior doeswhile also addressing his or her unique needs. The or does not occur, the duration (how long) a behaviorcurriculum for a young child with ASD needs does or does not occur, and the independent natureconcentrated or specialized instruction to address the of a behavior (how much support or prompting aareas of language, social interaction, play skills and child needs). In order to use data in reviewing theinterests. The essential areas for a specialized effectiveness of intervention, the following mustcurriculum for an infant or toddler with ASD include: happen:1. Attending to and staying engaged in the 1. An assessment is completed prior to intervention; environment, including people and 2. Outcomes and objectives are written in developmentally appropriate play materials; measurable and functional terms. There must be a2. Using verbal and non-verbal communication, specific description of the desired behavior; such as gestures, vocalizations and words; 3. Data on outcomes and objectives are taken prior3. Understanding and using language to communicate; to intervention and used as a baseline for intervention;4. Playing appropriately with toys; 4. Steps or tasks towards outcomes are analyzed5. Playful interactions with others; and defined;6. Reciprocal interactions; 5. Instructional strategies and supports are identified7. Spontaneous interactions; (e.g., where, when, with whom, level of support);8. Making choices; 6. Methods for motivating or reinforcing the desired9. Following daily routines and variations in routines; behaviors are identified; and 7. Methods and timelines for measuring progress10.Addressing atypical sensory preferences and are determined; aversions.4 Early Intervention Colorado
  9. 9. 8. Data is taken and analyzed on a routine basis; and and their behavior. The principles are grounded in the9. Adjustments in intervention plans are made based appreciation of each child’s strengths and needs. To on analyzing progress on the IFSP outcomes. practice PBIS means getting to know the whole child and assuming his or her behavior has meaning andOngoing collaboration between the family and service that the behavior is a form of communication. Itproviders in the analysis of data and adjustment of requires recognizing that a child develops andstrategies is a key to successful teaching and responds best when he or she is respected andlearning. Continuation of ineffective strategies or supported to enjoy relationships and make choices.relying on techniques merely because they have been Challenging behaviors displayed by a young childshown to be effective with other children may be with ASD are complex and may create frustration andharmful. Many early intervention providers find that a confusion for those who interact with the child.regularly scheduled meeting of all team members Behavior may range from aggression, tantrums, or(including the family) is important to review data, self-injury to withdrawal or repetitive, stereotypicalmaintain consistency in intervention, and make actions. Some of these behaviors also occur in atimely changes in the intervention. It is also essential child who is typically developing. For an infant andthat services are carefully coordinated and involve toddler with ASD, behaviors can be extreme, occurthe disciplines needed to address the unique needs of more frequently, disrupt development, or contributethe child and family. to high levels of stress among family members. Before developing IFSP outcomes and strategies to■ Principle 7: address problem behavior, a thorough assessment ofInfants and toddlers with Autism the behavior must take place. This assessment,Spectrum Disorders should have regular which may be referred to as a “functional behavioraland deliberate exposure to typically analysis,” is completed by the appropriate membersdeveloping peers. of the IFSP team and is designed to answer questions, such as “Why is the behaviorThis empirical and values based principle has, at its happening?,” “When does the behavior occur?,”core, two irrefutable facts. First, children with ASD “What function does the behavior serve?,” “Is theexperience significant social relationship delays that behavior preceded by any biological, environmental,represent primary diagnostic criteria (Luisell, Russo, sensory, and/or emotional conditions?” TheChristian, Wilczynski, 2008; Mahoney & Perales, 2003; assessment also looks at what happens after theStrain & Schwartz, 2009). Second, by a wide margin, behavior occurs, “How do people respond to thethe most effective intervention in this domain involves behavior?” The assessment helps the teamteaching typically developing children to be therapeutic understand how their response to the child’sresources (National Autism Center, 2009; Strain & behavior may increase or decrease the behavior.Bovey, 2008). For children ages birth through twoyears of age, this means involvement in Once the assessment is completed, a PBIS plan ispreschool/childcare settings, “play dates,” or planned developed as part of the IFSP. The plan includesinteractions between siblings, where the early developing strategies to keep the behavior fromintervention provider could facilitate peer training occurring, providing the child with new skills toscenarios. replace the undesirable behavior, and assisting family members or other caregivers to respond to the behavior in new ways. The ultimate goal of the■ Principle 8: plan is to help the child and family gain access toChallenging behaviors are addressed new activities and settings, have positive socialusing positive behavioral interventions interactions, develop friendships, and learn newand supports (PBIS). communication skills. The result of the support should be that the child has fewer problemPBIS (Carr et al, 2002) is a set of principles that behaviors and more typical ways of interactingframe how to think about and respond to children with others. Early Intervention Colorado Autism Guidelines for Infants and Toddlers 5
  10. 10. Whether a child is using an alternative■ Principle 9: communication system or not, communicationIntervention should focus on developing interventions noted in the IFSP should focus on thecommunication skills. development of functional communication, including receptive and expressive language skills such asThe importance of having an effective communication getting someone’s attention, requesting,system cannot be underestimated. Communication is commenting, pointing to objects, asking for help andmuch broader than simply talking to others. A good greeting others appropriately.communicator uses verbal, as well as non-verbalbehavior to engage a listener. Infants and toddlerscommunicate to make their needs known long before ■ Principle 10:they can talk. As young children develop, their non- The development of social relationshipsverbal communication (i.e., pointing to desired object, is integral to successful outcomes.lifting their hands to be picked up) becomes naturaland is understood by others. Young children with In addition to difficulties with communication, infantsASD, whether verbal or non-verbal, must develop and toddlers with ASD typically lack appropriatesome type of communication system in order to be interaction and social skills. Intervention for a childsocially successful. They must be able to with ASD needs to specifically address this core,communicate in a manner that others will understand. defining characteristic as early as possible.Some toddlers with ASD lack verbal communication Promoting the social development of infants andwhile others with ASD may often have large toddlers with ASD must be one of the primary goalsvocabularies or imitate spoken language well, but lack of early intervention services, as is facilitating thejoint attention skills or functional use of language to ability of young children with social delays to developcommunicate. Alternative or augmentative appropriate friendships. With early and intensivecommunication systems are one way to assist a intervention, the seemingly pervasive social skilltoddler who has limited verbal language. The type of deficits of many children with ASD can be remediatedcommunication system used varies depending on the (Lovaas, 1987; McGee, Daly & Jacobs, 1993; Strain,child and the activities and environments in which he 1987). To successfully target these important skills,or she spends time. The system may include simple intervention efforts, even within early intervention,gestures, sign language, objects, pictures, or an must include: a) regular access to typical peers, b)electronic communication device. The use of an thoughtful planning of meaningful social situationsalternative system does not mean that the child does embedded throughout the day, c) the use of “social”not develop verbal language skills or speech. The toys, d) multiple-setting opportunities (home-communication system is used as an aid to improve inclusive, community-based) to practice emergingcommunication and speech, increase social social skills, and e) intensive data collection in orderinteractions, and provide structure to daily activities to make midcourse corrections to existingor routines. Because a child with ASD tends to have intervention plans (Strain & Danko, 1995).strong visual skills, he or she is often successful withpicture communication systems such as the PictureExchange Communication System (PECS) (Bondy & ■ Principle 11:Frost, 1994). If a child has difficulty understanding Getting to quality outcomes is not justspoken communication, pictures are often used to about hours of direct services.give more information. For example, a child may be There can be no doubt that achieving qualityoffered a choice of what he wants to play with by outcomes is first and foremost on the minds ofshowing him two pictures. The child chooses what he families affected by ASD. In many situations, and foror she wants by pointing to the picture or handing it many years, families and providers have assumedto the adult. The purpose of an alternative system is that getting a certain amount of hours of directto expand the ways in which the child can interact service or a certain intervention practice is thewith and be understood by a variety of people. essential ingredient to achieving quality outcomes.6 Early Intervention Colorado
  11. 11. Regretfully, this simple and seductive formula is can assume that skill acquisition is occurring. Insteadhighly questionable and misleading. of asking, “How many hours of service are on the IFSP,” the alternative question could be, “Are theRelated to the amount of service hours, much of the IFSP outcomes, strategies and corresponding earlyfocus has been on an “estimated” 25 hours per week intervention services sufficient to influence the child’sthat was part of the National Research Council’s engagement across all daily routines (dressing,(2001) report on early treatment for ASD. Essentially eating, play, bedtime, etc.)?” Intensity with infantswhat the report authors did was add up the hours and toddlers must also be sensitive to the fact thatdelivered in eight preschool (not infant–toddler) essential interventions can be delivered across manymodels with varying efficacy data and then divided by routines by adult family members who have beenthe number of models to yield an average of 25 coached by providers in specific teaching strategies.hours. The models in fact ranged in hours from 15– Moreover, it should also be kept in mind that infants40 and the report clearly states that no clear outcome and toddlers with ASD (and any similar age children)differences were evident across hours. As was true require adequate time during the day for rest andthen, it is still the case that there are no credible sleep. Very young children are simply notstudies in which the same intervention has been “developmentally available” for the same level ofdelivered at different levels of hours. For a variety of intensive intervention as are older children.ethical and practical reasons, it is doubtful that suchresearch will ever be available. Factor 2. Fidelity of intervention delivery. Selecting anSimilarly, there has been a narrow focus on delivering “Established Intervention” does not guarantee thata singular intervention approach. Some individuals the infant or toddler will receive the intendedadvocate for only Pivotal Response Training, or approach. It is essential to ask what experienceDiscrete Trial Instruction, or Incidental Teaching, and providers have with the intervention approach, doso on. The problem is that these Established they have a protocol for judging that the interventionInterventions vary greatly in their relative efficacy for is correctly implemented and what are the plans ifcertain target behaviors. For example, Peer-Mediated intended outcomes are not forthcoming.Intervention has been shown to be the strongestevidence approach for target behaviors in the social Factor 3.domain. Incidental Teaching has been used almost Social validity of goals. Social validity refers to theexclusively with verbal language behaviors. degree to which there is an immediate impact on theSchedules are particularly helpful during transition child’s quality of life when a particular goal or objectivetimes, and so on. The point is that no one approach has been met. For example, teaching a toddler to labelcan hope to yield the best outcomes across all the colors when presented with 3x5 cards of differentlikely goals of any child or family. colors would have low social validity compared to teaching the same toddler color recognition when aIf a narrow focus on hours or a narrow focus on getting peer at an art table says, “Do you want some red?” ora certain intervention model is not recommended, then when his or her mom says, “Want your red or bluewhat are the relevant factors? There are five evidence- pajamas?” In the later cases, the child’s new colorbased factors that are suggested. knowledge can directly control his or her environmentFactor 1. and meet immediate needs. Therefore, this teachingIntensity. While hours of service may not be a goal would have high social validity.particularly valid measure of intensity, intensity is a Factor 4.highly relevant factor. The alternative view of intensity Comprehensiveness of intervention. One of theis based on several decades of research showing that more clear findings from the last several decades ofthe level of children’s active and appropriate intervention research on children with ASD is thatengagement in everyday routines is a powerful progress in one domain of performance has apredictor of developmental growth (McWilliam, et al, minimal impact on other domains (Lovaas, 1987;2009; Strain & Schwartz, 2009). That is, when young National Research Council, 2001; Strain & Hoyson,children are actively and appropriately engaged, one 2001). This widely replicated finding necessitates an Early Intervention Colorado Autism Guidelines for Infants and Toddlers 7
  12. 12. approach to IFSP design that addresses all relevant starting something new and different. During thedomains of performance for children receiving early transition to a school-based program at age three,intervention services. there are changes in adults, children, settings, and routines. Children with ASD may be so sensitive toFactor 5. change as to notice differences that others do not.Data-based decision-making. As has been emphasized There are significant differences between theelsewhere in this guidance document, a key component service delivery model used in the earlyto effective early intervention is to install a data intervention program and that of a programmonitoring system and related decision-making developed by a local school district for specialstrategies to optimize the delivery of effective services. education services. Planning and flexibility on theIn considering all five factors, one might pose that part of early intervention providers and preschoolthe formula associated with quality outcomes is programs are necessary to assist families andactually multiplicative. That is, the formula is as young children with adjusting to this change.follows: When planning the transition from an early(Intensity) x (Fidelity) x (Social Validity) x intervention program at age three years to a(Comprehensiveness) x (Data-Based Decision-Making) = preschool educational program, the following areQuality Outcomes helpful:In this formula, the fundamental message is that asany factor approaches a “zero value” then the sum or 1. The earliest possible referral, with parent consent,outcome will approach zero as well! The formula also to the local school district for a preschool (Part B)suggests that for many infants and toddlers with ASD evaluation;the resulting plan may well involve a large number of 2. The earliest possible communication, with parenthours of direct service. The key difference is that the consent, to the school district about the strengthsnumber of hours should be the product of a carefully and needs of the child and family;designed IFSP and not determined arbitrarily. As 3. Details of the early intervention service(s) that arementioned earlier related to Factor 1 (Intensity), the in place and strategies that have been successful;ultimate number of hours must be sensitive to the anddevelopmental availability of infants and toddlers ingeneral to engage in instructional episodes. 4. A focus on supporting the family, as well as theRelatedly, research by Dunst and colleagues suggest child, throughout the transition process.that IFSPs that result in families having a narrow and Unfortunately, many young children with ASD dosole focus on getting the maximum amount of not present their complex needs until very shortlyintervention may have harmful effects on both family before their third birthday. If that is the case, earlyfunctioning and on ultimate child outcomes (Dunst, intervention providers must work diligently to helpTrivette & Hamby, 2007). parents understand the need to share information with the school district as soon as possible.Implementation of these guidelines will ensure that Transition and transition activities should be amore and more infants and toddlers and their major focus of IFSPs for all toddlers with ASD,families affected by ASD will achieve the quality especially for those nearing the age of three.outcomes they desire and deserve. Similarly, cooperation between the early intervention program and the school district is■ Principle 12: essential for effective transitions. Prior to theThe transition from the early intervention transition conference meeting, it may be helpful toprogram to preschool special education and identify skills that can be introduced at home butrelated services should be well planned. that will be helpful in a school-based program. In addition, community resources for necessaryToddlers with ASD often have difficulty with family supports should be identified that may notchange, including change experienced when be available from the school.8 Early Intervention Colorado
  13. 13. Detailed Guidance for KeyPractice IssuesThe following sections offer a wide variety of both moving the services into the child’s naturalconceptual and practical strategies that providers and environment;families can use to help guide the development, 6. When services will be scheduled and coordinateddelivery and monitoring of IFSPs for infants and to achieve targeted outcomes;toddlers with ASD. 7. Number of visits or sessions the child will receiveStrategies For Designing IFSPs for each service and how long each will last;The IFSP is a process that uses a written plan to: a) 8. Whether the service will be provided one-on-one,document current levels of development, b) identify in an inclusive community setting or throughfunctional learning objectives for the identified child consultation with a caregiver or provider;and family, and c) specify early intervention services 9. Who will pay for the services;needed by the eligible child and family. The IFSP 10.Name of the service coordinator overseeing theprocess is directed by and developed jointly with the implementation of the IFSP;family, other individuals of the family’s choice,members of the assessment team, the service 11.Steps to be taken to support the child’s transitioncoordinator and appropriate early intervention service out of the early intervention program and intoproviders. While the general process for the another program when the time comes;development of an IFSP is well documented in the 12.The IFSP may also identify other services theEarly Intervention Colorado policies and procedures, family needs, but are not required under Part Cas well as information for families, (see A Family of IDEA;Guidebook, Guide II: The Individualized Family 13.The IFSP needs to be reviewed, and updated ifService Plan and Orientation to Early Intervention appropriate, at least every six months and isServices at www.eicolorado.org), the following rewritten annually;bullets describe some key ingredients that shouldcharacterize all IFSPs: 14.The IFSP must be fully explained to the parents, and their suggestions must be considered; and1. Family information, including their resources, concerns and priorities for their child as identified 15.The parent must give written consent before by the parents through interviews, assessments services can start. and informal contacts with the service Creating an IFSP that meets the needs of infants and coordinator, early care and education staff, toddlers and families affected by ASD is, in many doctors, nurses and other family members; cases, a complex and evolving process. The available2. The child’s present physical, cognitive, research base for early intervention service delivery communication, social emotional, and adaptive to infants and toddlers with ASD is quite limited. The development levels and needs, obtained from a evidence-based practices are evolving as early multidisciplinary evaluation; intervention providers and researchers use ongoing data systems to guide the developing body of3. Functional outcomes expected to be achieved for knowledge about how to determine what services, the child and family in the following six months methodologies, intensities and frequencies yield and the strategies to meet those outcomes; meaningful behavioral change in young children4. Specific services the child will be receiving; under the age of three years.5. Where the services will be provided within the In the absence of definitive research on child’s natural environments (e.g., home, interventions for children under age three, it is childcare). If the services will not be provided in recommended that IFSP teams ask themselves the the natural environment, the IFSP must include a following questions to guide the IFSP planning statement justifying why not and strategies for process for infants and toddlers with ASD in order Early Intervention Colorado Autism Guidelines for Infants and Toddlers 9
  14. 14. to support the delivery of services that are Question 5.individualized, evidence-based and Is there a plan in place to use a primary providercomprehensive (this list is also provided in service model or, where multiple providers are seeingAppendix A for teams to use): the child, a plan to meet frequently to communicate, plan logically consistent services and reviewQuestion 1. progress?Have assessment strategies been utilized todocument the child and family needs identified in the Question 6.IFSP that are: Do the planned strategies include ongoing data collection (see section on “Monitoring Progress”a) Specific (observable, measurable, and valued by pp. 34–36) and clear decision-making guidelines family members)? regarding the continuation or modification of theb) Functional (related to specific skills that help the plan that results in progress for meeting child and child access everyday life)? family outcomes?Question 2. Together, the practice principles discussed in theAre there evidence-based strategies in place on the previous section with the straightforward answers toIFSP that: these questions will help to ensure that IFSPs area) Address each area of need identified by the team? sufficiently comprehensive, designed to produce functional outcomes in essential real world settings,b) Match functional outcomes that include are utilizing evidence-based practices, and are addressing the defining characteristics of ASD delivered in a competent, coordinated and data-based (communication, social skills, and behavioral fashion. In order to maximize the child’s skill concerns)? generalization across persons, settings and time, it isc) Specifically address the child and family being essential to first consider the child’s planned learning successful with daily routines (e.g., dressing, opportunities delivered by adult family members feeding, bedtime, community outings, etc.)? and/or adults in other inclusive community settingsd) Include strategies to equip family members with prior to determining the number of direct service the information and skills needed to provide hours on the IFSP. consistency in intervention when early For children with ASD, we suggest the use of two intervention providers are not present? tools to help parents identify and communicate theQuestion 3. current levels of functioning for their children duringHas the IFSP team carefully considered the following everyday experiences at home and in the community.questions, taking into account the child’s One example is the About Our Child assessment tool,developmental availability for intervention and the (Strain, 2002) (see “Appendix B”) that aids parents orfamily’s dynamics and available resources: other caregivers in identifying skills their children currently demonstrate in common everyday activitiesa) What early intervention services are needed to and routines. Additionally, the tool helps to identify implement the evidence-based practices? skills that parents would like their children to learn inb) Who will deliver the services? these areas. The About Our Child document starts byc) Where the services will be provided? asking parents or other caregivers to list what the child can do in the following areas:d) When and how frequently the services will occur?e) What available funding sources will be accessed? a) Play—Skills such as appropriate toy play, sharing, taking turns, playing by themselvesQuestion 4. (independence) and playing with other children.Are the proposed providers fluent with the evidence-based practices to be delivered? If not, what plans b) Language—Includes skills such asare in place to provide training, supervision or communicating wants and needs, followingcoaching for those providers? directions, listening skills, understanding concepts (e.g., in, on, up, etc.).10 Early Intervention Colorado
  15. 15. c) Adaptive—Skills such as dressing, hand washing process and helps determine what skills or behaviors and toileting. a child must learn to be successful in daily routines.d) Meal Time—Skills such as eating with utensils, This protocol is an excellent supplement to About eating a variety of foods, using a cup and sitting Our Child as it more directly pinpoints the daily at the table for meals. routines that will serve as the context for service delivery. Further description of the RBI can be founde) Bath Time—Skills such as sitting in the tub, at www.siskin.org/www/docs/112.190. washing body parts, brushing teeth, combing hair.f) Cognitive—Includes skills such as understanding A Tiered Model For Thinking About Specific simple stories, identifying pictures of objects, Needed Early Intervention Services letters and numbers, shapes, colors, matching This section of guidance provides the reader with a and sorting. general approach for building a set of IFSP servicesg) Motor—Covers gross motor skills like running based on a thorough review of needs and and jumping, rolling, catching and throwing a ball preferences. One of the great challenges in the early and fine motor skills including opening intervention field is the brief time period available for containers, turning door knobs, holding crayons the delivery of services to infants and toddlers with and markers, using scissors and playing with ASD. Even in the best case, it is likely that IFSPs will material like play dough. be in place for no more than 18 months, and many will be in place for much shorter periods of time. Inh) Community Activities—Skills such as sitting in a such a “time-critical” circumstance, it is essential cart at the grocery store, riding in a stroller, that services are optimized to yield the most playing at a playground and riding in the car. functional and powerful outcomes in a context wherei) Behavior—Behaviors that interfere with learning, public resources are scarce. It is in this complex that the parents would like their child to do less context that the following model is offered as a often, are aggressive, self injurious or deal with general guide for conceptualizing and planning early sensory sensitivities. intervention services.After parents have a chance to list the skills the child The tiered model being advanced for infants anddemonstrates across these areas they are asked to list toddlers with ASD is based on the three-level modelnew skills they would like their child to learn in each of of prevention that has been increasingly common inthese areas. Because parents spend time with their many arenas of social services, including publicchild doing these things on a daily basis it can provide health and education (e.g., Fox, Dunlap, Hemmeter,assessment teams valuable information regarding the Joseph, & Strain, 2003; Simeonsson, 1991; Sugai etchild’s functional skill set throughout the day which al., 2000; Walker et al., 1996). The model begins bycan be used alongside any additional formal or defining target behaviors in need of prevention, suchinformal assessments the team has conducted. Ideas as social isolation, destructive/disruptive behaviorsgenerated through the About Our Child can be shaped by infants and toddlers with ASD, or high levels ofdirectly into goals and/or objectives on the IFSP. parental stress. Strategies intended to prevent theMoreover, the form is a good starting place for occurrence or further development of the targetbuilding an intervention that is contextually relevant to behaviors are then categorized along a hierarchythe everyday activities that the family experiences. The related to the proportion of the population for whomform may be completed by the parents or other the strategy would be pertinent, the intensity of thecaregivers themselves or the service coordinator or strategy and in terms of the stage of the targetprovider may gather this information through an behavior’s development.interview process with the family. Level 1 Strategies:A second recommended tool to gather family Building Positive Relationships, Supportiveinformation is through the use of the Routines-Based Environments, and Healthy PhysiologiesInterview(RBI) (McWilliam, 1992, 2005, 2008). The Level 1 strategies are intended for the entireRBI is a part of a functional intervention planning population of infants and toddlers and families Early Intervention Colorado Autism Guidelines for Infants and Toddlers 11
  16. 16. affected by ASD or challenging behaviors. The intensive and costly than Level 3 strategies. Still, forstrategies are geared to an early stage of prevention infants and toddlers with ASD, due to their substantialand are relatively inexpensive and easy to implement. risk factors, it is likely that a relatively large segmentThis level is referred to as primary prevention, of the population will require and benefit from Level 2involving universal applications. For example, a strategies. Level 2 strategies, to a large extent, areuniversal strategy for the prevention of disruptive based in the science of Applied Behavior Analysisbehavior might include establishing a functional (ABA) (Baer, Wolf & Risley, 1968). Examples ofsystem of communication, especially one by which additional Level 2 strategies include using naturalisticthe individual can readily express wants, needs and teaching strategies like incidental teaching, Pivotalirritants. A universal strategy to prevent parent stress Response Training and modeling to teach appropriatethat interferes with the child’s development might play skills, increasing engagement and motivation,include guided opportunities for family members to using antecedent prompting to prevent challengingdiscuss issues they face with others in similar behaviors, discrete trial instruction and the utilizationcircumstances. Universal strategies for infants and of peer-mediated interventions.toddlers with ASD would be implemented for all Level 3 Strategies:children and families, as early as possible. Additional Individualized Intensive Interventionsexamples of Level 1 strategies include building Level 3 is for infants and toddlers and their familiesstrong parent–child relationships, including a focus who are already displaying the target behaviors andon joint attention, environmental organization, the require relatively intensive and individualizeduse of visual schedules and ensuring sound physical interventions. This level is referred to as tertiaryhealth for the infant or toddler. prevention, with individualized, intensive interventionLevel 2 Strategies: procedures. Level 3 involves individualizedBuilding Social and Communicative Competencies assessment and assessment-based interventions thatInconsistent with Problem Behavior are relatively well-represented in the current literatureLevel 2 is referred to as secondary prevention, and is on PBIS and ABA. Level 3 also assumes thatintended for young children for whom Level 1 is providers will work, in part, with an individual infantinsufficient and who are clearly at risk for, or who are or toddler and his or her family on a one-to-onealready demonstrating, early indications of the basis. These strategies are markedly more expensivenegative target behaviors. For infants and toddlers in terms of resources and time required than Levels 1with ASD, Level 2 might include specific procedures or 2. It is important to clarify that Level 3 is not justdesigned to teach appropriate problem solving, self one level of intensity. It is actually a set of proceduresregulation and coping, and to divert them from using on a continuum of intensity that is based on theproblem behavior. An example of a Level 2 strategy extent to which challenges are severe, long-lasting,for a two year-old who has as an objective to wait for and demonstrably resistant to change. For example, ifthree seconds before accessing a requested item a toddler is beginning to display tantrums at home,would be the use of a large size visual and auditory but the tantrums are limited to one or two dailytimer. Once the timer signals the end of a three- occurrences (i.e., seeking attention at mealtimes) andsecond interval, the mother can grant access to the have not been exhibited in the community or otherrequested item. This could be done during simple settings, then the procedures need not be as timehome routines, such as the toddler and another consuming or especially effortful (though they mayfamily member (a sibling, the father, and aunt) taking still require individualized assessment and anturns to request a favorite snack item and waiting for individualized intervention plan) (Dunlap & Fox,three seconds for its delivery. 1999; Strain & Schwartz, 2009). On the other hand, if a child has demonstrated severe problem behaviorsLevel 2 strategies to prevent parental stress might for several months, and the problems have persistedinclude systematic, group-based training in strategies in many environments despite multiple efforts atthat make daily routines more enjoyable. Level 2 remediation, then the Level 3 process is likely tostrategies are more focused than Level 1, involve a require a considerable investment of time andsmaller proportion of the population, and are less resources to be effective.12 Early Intervention Colorado
  17. 17. LEVEL 3: Individualized Intensive Interventions LEVEL 2: Building social and communicative competencies inconsistent with problem behavior LEVEL 1: Building positive relationships, supportive environments, and healthy physiologiesFigure 1. Tiered Intervention Model for Children with Autism Spectrum DisordersThe multi-tiered prevention model is represented in typically developing child. Therefore, it is importantFigure 1. The bottom tier, Level 1, is intended for all to take concerted measures to reduce potentialinfants and toddlers with ASD and other young irritants and to teach the child, from a very early age,children with severe communication and/or that interacting with the social environment isbehavioral delays, while Levels 2 and 3 build pleasurable and satisfying. Level 1 strategies areincreasingly focused and intensive supports for those geared to all children with a diagnosis or likelyinfants and toddlers who demonstrate high risk classification of ASD and they should befactors and needs related to overall development and implemented as soon as possible.problem behaviors. The following descriptions One category of Level 1 strategies involves theprovide further details on of the three levels along development of positive relationships betweenwith examples of intervention strategies. Much parents (and other family members and caregivers)greater detail on evidence-based strategies is and the infant or toddler. The intent is to teach thecontained in the “Evidence-Based Interventions and child that parents and caregivers can be relied on asMeasuring Outcomes” section of these guidelines. stable, secure, and safe figures that provideLevel 1: nurturance, comfort, pleasure and guidance.Strategies for infants and toddlers with Developing attachments is a challenge for an infantAutism Spectrum Disorders. or toddler with ASD, so special efforts are required, even when signs of a child’s interest are notIt is understood that infants and toddlers with ASD apparent. This might require that a parent orhave more difficulties interacting with and managing caregiver identify the activities, objects, settings, andtheir environments than young children who are interactions that the child finds pleasurable andtypically developing. As a result, there are provide those events and items to the childundoubtedly more events and circumstances in the contingent on a social interaction behavior (ratherenvironment (including the child’s physiological than non-contingently in a manner meant to keep aenvironment) that can be irritants to the child, and child satisfied without social interaction). Forwhich cannot be resolved as efficiently as with a example, a tickle game might be initiated with a child Early Intervention Colorado Autism Guidelines for Infants and Toddlers 13
  18. 18. and then interrupted by the caregiver with the that the child communicate or socially interact can beexpectation that the child look at the adult or repeat a detrimental to the child’s potential for developing agesture to continue. A key objective of efforts to form repertoire of social and communication skills.positive relationships is to ensure that the Third, a key category of Level 1 strategies involvesinteractions are pleasurable and that they are procedures to insure that the child’s physical healthassociated with the child receiving input that is is sound, that somatic complaints are understoodconsistent with needs and interests. Importantly, and addressed, that the child has daily opportunitiessuccessful efforts to form strong, positive bonds for vigorous exercise (e.g., Kern, Koegel, & Dunlap,when a child is very young result in a subsequent 1984), and that the child consumes food andrelationship in which an adult has considerable beverages that are nutritious. A child’s physiologicalinfluence over a child’s behavior, and this influence well being is an important factor in preventing thecan be essential for the guidance and instruction that emergence of problem behaviors as it is likely thatthe adult (parent or other caregiver) must provide on some problem behaviors begin as simplean ongoing basis. expressions of internal discomfort (e.g., cryingA second category of Level 1 strategies involves the elicited by a stomachache) which are thenprovision of a safe, comprehensible, stimulating and inadvertently shaped by external contingencies (e.g.,responsive environment. As a young child with ASD provision of attention) into full-fledged problemoften has difficulty navigating their surroundings, it is behaviors (e.g., violent tantrums). The relationshipuseful to be sure that clear physical cues are between physiological circumstances and problemconsistently available to help a child locate desired behavior has not been studied extensively, howeveritems and to make appropriate requests. The there is no doubt the link is a powerful one and thatunderstanding of the environment, schedule, and improved medical assessment and care can be arequests is often enhanced through the use of visual powerful Level 1 strategy of prevention (Carr &supports or object cues that provide the child with Owen-DeSchryver, 2007).additional information on what is expected (e.g., And, finally, Level 1 also includes intentionalDettmer, Simpson, Myles, & Ganz, 2000; Olley & instruction to help infants and toddlers acquireReeve, 1997). Similarly, toys and other objects of functional communication skills needed to effectivelyinterest should be available, especially of the type and conventionally control aspects of thethat occasion social interaction. For example, books environment. For example, even when a child has noprovide an excellent opportunity for turn-taking other distinguishable language, parents can help aexchanges and exposure to print language. Other toddler with ASD to use vocalizations or gestures totoys, such as balls, blocks, and art materials are request or reject objects and activities, and they caneasily used to support the child’s motor, cognitive, help build communication exchanges by respondingand social development. In addition, the environment to the child’s nonverbal expressions as comments orshould be set up so that a child’s initiations are met requests for information. A young child’swith appropriate responses, along with guidance and communicative competence is one of the mostsupport to sustain interactions and help insure that salient factors related to the extent that the child withthe child’s motivations are fulfilled. A correlate of this ASD develop social relationships and achieve desiredcategory is that a child with ASD should be exposed lifestyle outcomes (Woods & Wetherby, 2003). Ato a variety of community and social contexts, while focus on the development of communication andbeing supported by assistance and positive guidance language skills should include an emphasis on theto insure that these experiences are enjoyable and forms of communication (e.g., from using gesturessuccessful for the child. The active engagement of to words) as well as the pragmatics ofthe child within meaningful activities and social communication (e.g., the social process ofinteractions is pivotal to the child’s overall communication) including initiating interactions,development and ability to navigate social establishing joint attention, and maintaining aenvironments (Kohler & Strain, 1992). Thus, the conversation. For the child with ASD, it is necessarypervasive use of passive activities (e.g., watching to pursue this kind of instruction intentionally andvideos, playing alone repetitively) that do not require14 Early Intervention Colorado
  19. 19. deliberately and, always, with awareness of what the peers. They illustrate such environments withinstruction does to help the child be an active reference to two model programs: LEAP (Learningparticipant and, to some extent, manager of his or Experiences: An Alternative Program), developed byher surroundings. Strain, and Project DATA, developed by Schwartz. Embedded within the programs’ structure andIn addition to the instruction of communication skills, curricula are Level 2 strategies designed to buildthe toddler with ASD most likely needs explicit skills and simultaneously reduce the probability ofinstruction and support to meet other developmental problem behaviors. One strategy is an “appropriatemilestones, including self-care skills (e.g., assisting engagement strategy” in which the procedural focuswith dressing or toileting), play skills, independence, is on increasing children’s appropriate engagementand some motor skills (e.g., using a crayon or a with materials and activities. Although not designedspoon). The promotion of the toddler’s overall skill explicitly as an intervention for problem behaviors,development often requires repeated, intentional, increases in engagement tend to be related toinstructional episodes and the provision of reduced occurrences of problem behavior and, thus,systematic prompting and encouragement to assist the engagement serves as a strategy for preventingthe child in achieving independence. problems without an intensive behavior interventionLevel 2: plan (Kohler & Strain, 1992; Dunlap & Strain, 2009).Strategies for infants and toddlers with For example, for a child who wanders around theAutism Spectrum Disorders. home, climbs on furniture or dumps out baskets of toys, teaching simple play skills like building withWhile Level 1 strategies involve the provision of blocks, pushing cars or doing puzzles not onlyexperiences and supports that are reasonable for any increases appropriate engagement, but also likelyinfant or toddler, regardless of the child’s abilities and decreases the amount of time the child spends in thechallenges (though strategies for infants and toddlers inappropriate behaviors listed above.with ASD may require more intentional effort on thepart of the parents or caregivers), Level 2 strategies Level 2 strategies are also found in manyinvolve specific procedures designed to enhance a comprehensive programs for helping young childrenyoung child’s behavioral competencies and, with ASD (e.g., Koegel & Koegel, 2006; Mahoney &indirectly, help prevent the development or display of Perales, 2003). Such strategies are oftenproblem behaviors. Level 2 is for infants and toddlers components of the larger program that can bewith ASD for whom Level 1 is insufficient and who implemented in home and community contexts,have risk factors that indicate a need for more whether or not the comprehensive program isdeliberate strategies. Such risk factors include available. For instance, Pivotal Response Treatmentsobvious delays in language development, notable (PRT) (Koegel & Koegel, 2006) is a unified andavoidance of social interactions, and a failure to comprehensive approach to intervention for childrenacquire functional skills. These criteria suggest that a with ASD. Included within the program are numerouslarge proportion of infants and toddlers with ASD procedures that are useful for increasing themay require Level 2 supports, and that is indeed the motivation and engagement of children with ASD,case, though the actual proportions are unknown and and such variables serve not only to enhancemust await the completion of considerable research. children’s cognitive, communicative and social development, they also serve to prevent problemStrain and Schwartz (2009) provide examples of behaviors. Examples of such procedures includeLevel 2 strategies for preventing the development of following the child’s lead, using preferred items orproblem behaviors in the repertoires of infants and activities, providing clear instructions, teachingtoddlers with ASD. These authors note, first of all, within natural contexts, providing choices, discretethat a primary consideration of programs for young trial instruction, reinforcing the child’s attempts,children with ASD is to provide an environment that varying and interspersing tasks, and using naturallyis designed to prevent problem behaviors, promote occurring reinforcers (Koegel & Koegel, 2006). Inengagement and participation, and facilitate addition to PRT, other related evidence-basedsuccessful interactions with typically developing strategies include incidental teaching (McGee, Daly & Early Intervention Colorado Autism Guidelines for Infants and Toddlers 15
  20. 20. Morrier, 1999), modeling, various antecedent Implications for Implementationprompting tactics, and peer-mediated intervention The 3-tiered model carries two major implications for(see modeling on page 22). Such procedures involve practice. The first is that an early and concertedless effort and intensity than Level 3 strategies, yet emphasis on preventive strategies has the potentialthey can be extremely useful for promoting to influence a child’s development in the direction ofcommunication, social and cognitive development more pro-social behaviors and a lower likelihood ofand preventing the development of problem severe problem behaviors. It is reasonable to assumebehaviors. Please see “Evidence-Based Interventions that a proportion of infants and toddlers with ASDand Measuring Outcomes” section of these who eventually come to develop problem behaviorsguidelines for more detailed descriptions of Level 2 might be diverted from this negative trajectory ifinterventions. Level 1 and Level 2 strategies are implemented earlyLevel 3: enough and with sufficient intensity and consistencyStrategies for infants and toddlers with (Dunlap, Johnson, & Robbins, 1990; Strain &Autism Spectrum Disorders. Schwartz, 2009). Therefore, a major implication of the model is that much greater consideration shouldLevel 3 strategies are comprised of procedures that be given to Level 1 strategies such as healthcare, theare most readily associated with problem behavior provision of stimulating and enjoyable environments,interventions because these are the strategies that and supported participation in complex socialare implemented after problem behaviors have contexts. Supporting families to gain knowledge anddeveloped to the point that they have become skills of Level 1 strategies is critical to the ongoingacknowledged obstacles to early learning and healthy support they can provide to their children throughoutsocial emotional development, and when they their early childhood development and beyond.present threats to the physical and emotional safetyof the infant or toddler with ASD, peers or others in A second important implication of the model is that,the vicinity. even for infants and toddlers with very severe disabilities and prominent risk factors (e.g., anAt one time the predominant approach for problem absence of functional, conventional communicationbehaviors was based almost entirely on contingency skills), a solid foundation of Level 1 and Level 2management, in which interventions consisted of strategies should reduce the need for more labormanipulations of reinforcers and punishers. While intensive interventions at the tertiary level. Forcontingency management is still important, Level 3 infants and toddlers with ASD and their families,strategies have broadened considerably over the past the fundamental issue is that implementing Level 1two decades and now include a focus on and Level 2 strategies does not simply lessen therearrangements of the antecedent environment and need for more intensive supports, it often preventsinstruction on functional alternatives to the problem the onset of challenging behaviors, prevents adultbehaviors. Level 3 strategies now place a strong stress, and improves developmental functioning inemphasis on prevention rather than suppression. In key areas of communication and social skills. Theaddition, Level 3 interventions are generally preceded significance of this cannot be overstated. That is,by a process of functional assessment, designed to even if Level 3 strategies are needed, the presence ofidentify intervention components that address the Level 1 and Level 2 procedures will reduce the effortindividualized functions of the particular child’s associated with the Level 3 interventions that areproblem behaviors. The overall process of required to effectively address existing needs.assessment and intervention is commonly referred toas “positive behavioral interventions and supports”(PBIS) (Carr et al., 2002).16 Early Intervention Colorado

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